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�nuly SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax: (209)468-3433 Web: www.si4ov.orq/eh <br /> UNIT IV <br /> rkoie�' <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> 1800 N California St Mc Cloud St Stockton 95204 127-180-44 <br /> Site Location Cross Street City Zip APN <br /> PfePartySt Joseph's Medical Center 1800 N California St Stockton 95204 209-461-6818 <br /> Owner Address City Zip Phone <br /> C-57 Contractor Advanced GeoEnviroAddress 837 Shaw Road city Stockton Lie 95215 Phone 209-467-1006 <br /> Consultant/Sub Cntr AGE Address 1800 N California St city Stockton Lic95204 Phone 209-461-6818 <br /> Billable Pa 41 Josep s e� diul�tedddress 1800 N California St city Stockton Zip Phone <br /> Phone209-461-6818 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE POPRERFORMED: <br /> CH <br /> ®NEW <br /> SOIL BORING IDs G�;me DOrings HYDRl [O U) <br /> S SND-AUGER,OTHER) <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 1.5 in"MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS na TYPE OF CASING: 0 STEEL 0 PVC D OTHER <br /> 15-16EkSOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 7 feet TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE D PIPE <br /> _0 SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes eg No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(i.e.Air Soame.Oz")0 HAND AUGER GROUT SPECIFICATIONS Portland <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH 7 eet 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI <br /> _#OF WELL(S)TO BE DESTROYED E]OVER-BOREDIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,andapplica le lifornia laws. <br /> Signed W , Title/Company Geologist-AGE <br /> Print Name William Little Date qholo <br /> DEPARTMENT USE ONLY PAYMENT <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS RECFIVED <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DAT ISSUED OC U12_ <br /> GROUT INSPECTION BY FINAL INSPECTION BY I Z`F (3 ( QA.a� UIYA�MY <br /> ItONMENTAL <br /> DESTRUCTION INSPECT6W DATE HEALTH DEPARTMENT <br /> COM M ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> $125x ' +F X591 t N14/12—l9/12. SR# (,5 ?,3 <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2301 01/13/12 WELL PERMIT APP <br />